ELECTROCONVULSIVE

THERAPY
ELECTROCONVULSIVE
THERAPY

Jon Lehrmann MD
Assistant Professor of
Psychiatry
Medical College of WI
VAMC Milwaukee, WI
Mental Health Care Pre-1930’s
 History of ECT

• Von Meduna (1934)- Autopsies of patients

w/ Seizure disorders and of patients w/
Schizophrenia.
• Difference in Glial cell proliferation
Chemically induced seizures-
(camphor, pentylenetetrazol)
 Insulin Shock Therapy

• In the 1930’s , Dr Sakel developed Insulin Shock Therapy

 Cerletti and Bini (1934):
Electricity

Initially done without

muscle blocker or
anesthetic
 Early ECT
• Asylum
• Few effective medications
• Many often severe side effects
• 1950’s- ether, and curare extract developed (Abram
Bennett- a psychiatrist helped develop a method for
extracting curare).
• In 1950’s antidepressant and antipsychotic meds
introduced- significantly decreased utilization of ECT
 Electrophysiological Principles
• Ohm’s Law: I=E/R (I=current, E=voltage, and
R=resistance)
• Dose of electricity in ECT= 100-500 milliCoulombs
• Brain has low impedance (resistance), skull has
very high impedance. Only 20% of applied charge
actually enters the brain.
• Seizure involves propagation of action potentials in
a large percentage of neurons.
 Mechanism of Action
• Neurotransmitter levels all increased in CSF after
seizure. Results in down regulation of Beta
adrenergic receptors.
• During seizure- PET studies show an increase in
BBB permeability and in cerebral blood flow and
metabolism.
• After seizure, blood flow and metabolism is
decreased especially in the frontal lobes. Research
shows this correlated w/ response.
 Indications
• Major Depression w/ or w/o psychotic
features
• Bipolar disorder - manic or depressed phase
• Acute or Catatonic Schizophrenia
• Some studies have shown efficacy in treating
OCD, Delirium, NMS, Chronic pain
syndromes, and intractable seizure disorders
 Major Depression

• Efficacy vs antidepressants
• When is it a first line treatment
consideration?
• Length of Antidepressant effect
• Maintenance ECT
 Bipolar Mania
• Efficacy vs Lithium
• Indications for First Line Treatment:
• -Recent Myocardial Infarction w/ Acute Mania
• -Pregnancy w/ Acute mania
 Pre ECT Workup

• Physical Exam
• Head CT
• CXR
• CBC, Basic Chem
• EKG
• ? Spinal Films
 Contraindications?

• No Absolute Contraindications
• Relative Contraindications: Recent MI,
Berry Aneurysm, Brain Mass, Increased
Intracranial Pressure
 Treatments

• Premedicate w/ Glycopyrrolate, consider

short acting Beta blocker
• Patient not intubated
• Bite block
• Cuff leg to monitor sz
• EEG and EMG
• Length of sz- 20 sec to 1 min.
 Number and Spacing of ECT

• 2-3x/wk- efficacy vs less memory

impairment
• 5-12 sessions/ treatment (although up to 20
is possible)
• Point of maximum improvement- no more
improvement after 2 further treatments.
 Adverse Effects

• Mortality rate: .002% per treatment

session, .01% per patient.
• Sore Muscles
• Head ache
• Short term confusion/ delirium
• Memory
 Transcranial Magnetic
Stimulation (TMS)
• Rt Frontal lobe- TMS pulses suppress activity
and causes happiness and increased energy
• Left Frontal lobe- TMS pulses suppress
activity and leads to sadness
• 4/250 had seizure
• 10Hz stimulation 20x/day, 11/17 patients w/
Major Depression showed significant
improvement.
 TMS continued

• So far positive effects have not lasted as

long as positive effects from ECT
• Handful of case reports show efficacy w/
anxiety disorders.